Application Of A Patient Assessment And Care Plan Formulation

The assessment process is the back bone to any package of care and it is vital that it is personal and appropriate to the individual concerned. Although studies have found that there is no singular theory or understanding as to what the purpose of assessment is, there are different approaches and forms of assessment carried out in health and social care. These different approaches can sometimes result in different outcomes.

Nursing process is a systematic process that involves a continuous cycle of five interrelated phases: holistic assessment of a client, nursing diagnoses, nursing care planning, implementation, and evaluation (Wilkinson et al. 2015). It enables nurses to assess the person’s health status and health care needs, to create plans to meet the identified needs, and to provide and evaluate individualised nursing interventions according to the person’s needs (Luxford 2015). The holistic assessment is the first step of the nursing process that includes the collection of subjective and objective data related to the physical, psychological, social, developmental, cultural, and spiritual status of a client (Wilkinson et al. 2015). This comprehensive approach to nursing assessment is essential because it allows nurses to comprehend not only clients’ health status, but also their routines and needs in order to incorporate their life-styles into the care interventions (Luxford 2015). It ultimately enables nurses to provide appropriate quality person-centred care rather than nurse-initiated care (Luxford 2015). Responsibility for holistic nursing assessment is supported by the Registered nurse standards for practice (2016), ‘Standard 4.1: The registered nurse conducts assessments that are holistic as well as culturally appropriate’ (Nursing and Midwifery Board of Australia [NMBA] 2016, p. 4). This essay will discuss the elements and the importance of holistic assessment in nursing.

1.1 Explain the importance of a holistic approach to assessment and planning of care or support.

This assignment will define and analyse the need for a chosen service improvement within the pathway of mental health, as well as evaluating the suggested service. Demonstrating how this service can inform and benefit integrated practice, discussing the ways in which the agency’s statutory obligations and responsibilities impact on both individual and group decision making. The chosen service improvement for this assignment is the introduction of a mental health nurse into primary care services, for example, a GP Surgery. Focusing on service users with mental health issues in the community and therefore in the care of the local Primary Care Trust (PCT).

Within this essay, I will reflect and critically analyse an OSCE which has increased my awareness, or challenged my understanding, in assessing the holistic needs of a service user (John), referred by his GP, whilst incorporating a care plan using the Care Programme Approach (CPA). By utilising this programme and other sources of current literature, I hope to demonstrate my knowledge and understanding in relation to this skill as well as identifying areas with scope for learning.

Application of the holistic approach can be seen in the Biopsychosocial model used today in psychiatric and mental health nursing. The interdependent domains, biological (physical functioning), psychological (thoughts feelings and, behavior), and social (influence from family and communities) all come together with each having its own knowledge and treatment focus for the patient (source pg. 70). According to Stainback and Stainback (1988), holistic portrayal of events, procedures, and viewpoints in settings is often considered necessary to make accurate situational decisions. The approach helps to better understand the needs of patients so accurate care can be given. Therefore, when caring for a patient with a mental health illness, using a model such as the Biopsychosocial model is a good framework to reflect a good understanding of recognizing human beings

This assignment will explore and critically evaluate the role of the registered nurse in the development of a plan of care that is patient centred. This will involve examining and critically analysing the chosen nursing model in a holistic assessment of the patient and the use of the nursing framework ASPIRE (Barrett, Wilson and Wollands, 2012).

Assessment tools are used in the care planning process to build up a holistic picture of an individual’s needs. When all the details have been recorded an assessment can be made and suitable care and support can be identified. A few of the assessment tools are information from the individual such as diaries, observations, medical histories and checklists.

It is important to review care and support plans as people’s needs change. By including the person, their family then everyone knows what is happening and the family can help to monitor mood swings and behaviour. The individual and the family can express their views and preferences and any relevant risk assessments may be done with everyone involved. By monitoring the individual, a decision can be made as to whether the changes are effective and if the best care is being given to encourage independence and promote dignity.

Assessment is the initial stage of the nursing process. Roper et al consistently use the term ‘assessing’ to signify that it is an on-going process, and highlights its continuity throughout the patient’s episode of care (Aggleton & Chalmers, 2000). It is divided into two stages to allow for a holistic representation of the patient to be established (Barrett et al, 2009). Effective assessment allows the prompt identification of any changes in a patient’s health status, and if necessary; allows any action to be carried out immediately supporting the delivery of safe, effective care DH (). The formulation of an accurate assessment is a fundamental skill for a student nurse as outlined by the NMC (2004), and so it is important that a holistic approach is adopted for this skill to be achieved. An holistic approach supports the consideration of……..needs,(THEME?) which

The first stage of the process is assessment. Roper et al (2001) refer to this process as ‘assessing’ indicating an ongoing activity; this encourages nurses to recognise the on-going nature of this initial phase. The assessing stage includes gathering information about a patient, reviewing this information, identifying actual and potential problems and prioritising (Roper et al 2001). Roper et al (2001) explain the importance for assessing, as early as possible in the patient’s stay. Extensive, in-depth information may not be gathered on an initial assessment, however any information obtained contributes towards individualised care (Roper et al 2001). Ambrose and Wittig (1998) explain that the initial assessment becomes a foundation for ongoing assessing and holistic care. Barrett, Wilson and Woollands (2009) concord with Roper et al and Wittig in that assessing is an ongoing process and elaborate on this explaining that assessment should not be confused with admission. They state “an admission tends to be a one-off process when you first meet the patient, whereas assessment carries on throughout your relationship with the patient” (pg22). Assessment enables the nurse and patient to identify actual and potential problems. Although, some problems can be directly related to biological needs, holistic needs must be considered, i.e. psychological state and cultural/social standing

In this case study, there is a patient named Mr. Wilson who is a 70 years old man. He stated that he had difficulty in breathing and caught a ‘flu’ a week ago. Currently, he has been observed pitting oedema on his lower legs. In addition, the patient had history of heart attacks, which has been diagnosed with congestive heart failure. The case study will provide a complete care plan for the patient. Its aim is to provide a better quality of care for the patient as well as promoting holistic treatment of the patient. The report will firstly assess the patient’s condition by two nursing assessment tools while offering rationale for choosing these assessment tools. The client’s health problems will then be identified and

Nurses face many challenges everyday and it is essential to appropriately assess each patient before treating them. Having been an LPN for over seven years, I have learnt a lot and I continue to learn. Recently I had an experience with a patient that changed the way I complete my assessments due to the critical thinking I am currently learning in this program. According to Mariano (2005) nurses need to provide care for their patient’s with a holistic approach opposed to only concentrating on the medical symptoms that they are presenting, (Mariano, 2005, p. 48). I now pay more attention to the cognitive and psychological portions of my assessments. In this essay I will discuss a personal experience I had with a patient who was diagnosed with bipolar disorder, and alcohol abuse. He came into my ward experiencing suicidal ideations and hallucinations. Nurses need to develop care plans based on patients’ physiological, psychological, spiritual, and psychosocial domains to ensure they receive therapeutic care with a holistic approach.nice intro

In this case study, one day of care for a 28 year old, male patient on a low secure psychiatric unit will be examined and discussed. The main focus will be on implementation and evaluation of the nursing process. These areas will be covered under; physiological, psycho-sociological and pharmacological aspects of the patient’s care. Although, the case study is discussed using third person expression, the care discussed is what was implemented and evaluated by myself, a second year student nurse, under supervision from a qualified member of staff.

After providing a handout containing two questions to six of my nursing co-workers and then completing one, it was clear that the highest priority educational need that was mentioned was the care of cancer patients during treatment in our health care facility. In this paper we present patients' need assessment plan for cancer care. Covered in this work are the type of nursing care provided, the volume of activity of the institution, the levels of nursing care staff employed, sample selection technique, data collection method, data analysis, an identification of the highest priority learning need, institutional forces for as well as against responding to this need, identification of the next step which is needed in the institution and a conclusion to the topic.